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CASE report OPEN ACCESS Retained fecaliths after laparoscopic appendectomy disappearing spontaneously with non-operative management

Hideki Katagiri, Mai Ishitani, Takashi Sakamoto, Yasuo Yoshinaga, Tadao Kubota, Akira Miyabe

Abstract *********

Introduction: Intra-abdominal abscess after doi:10.5348/ijcri-2013-11-402-CR-16 laparoscopic appendectomy is a well-known complication. In cases of perforated appendicitis, the frequency of postoperative intra-abdominal abscess formation can be up to 20%. However, intra-abdominal abscess due to retained fecaliths Introduction has rarely been reported. A retained fecalith following appendectomy is a rare complication A fecalith is often detected in cases of acute and it has been reported that retained fecaliths appendicitis. It can drop pre- or intraoperatively into the should be removed immediately after their peritoneal cavity [1]. The frequency of retained fecaliths diagnosis because of its potential to cause after appendectomy is unknown and only a few case abscess. We present a rare case of retained reports have been published [2]. Postoperative abscess fecaliths after laparoscopic appendectomy which after appendectomy is a well-known complication and, in disappeared spontaneously with non-operative cases of perforated appendicitis, the frequency can be up management. to 20% [3]. A retained fecalith can cause intra-abdominal abscess and the abscess often relapses despite adequate Keywords: Retained fecaliths, Laparoscopic drainage [4]. Previous reports recommended the removal appendectomy, Intra-abdominal abscess of complicated fecaliths after diagnosis. We present a very rare case of retained fecaliths after laparoscopic ********* appendectomy which disappeared spontaneously with non-operative management. Katagiri H, Ishitani M, Sakamoto T, Yoshinaga Y, Kubota T, Miyabe A. Retained fecaliths after laparoscopic appendectomy disappearing spontaneously with non- CASE REPORT operative management. International Journal of Case Reports and Images 2013;4(11):650–653. A 70-year-old male was brought to emergency department complaining of abdominal pain for last three days. He had a past history of myocardial infarction, 1 1 1 Hideki Katagiri , Mai Ishitani , Takashi Sakamoto , Yasuo paroxysmal atrial fibrillation, hypertension, chronic renal Yoshinaga1, Tadao Kubota1, Akira Miyabe1 Affiliations: Department of Surgery, Tokyo Bay Urayasu failure and benign prostate hypertrophy. On physical Ichikawa Medical Center (Noguchi Hideyo Memorial examination, he showed severe tenderness of the right International Hospital), Chiba, Japan. lower quadrant and generalized peritonitis. Computed Corresponding Author: Hideki Katagiri, MD, 3-4-32, tomography (CT) scan revealed a swollen appendix Todaijima, Urayasu City, Chiba 279-0001, JAPAN; Ph: with several high density areas, which were compatible +81-(0)47-351-3101; Fax: +81-(0)47-352-6237; Email: with fecaliths, and pelvic fluid was detected (Figure 1). [email protected] We diagnosed him with perforated appendicitis and performed emergency laparoscopic appendectomy. On exploring the peritoneal cavity, a small amount of dirty Received: 27 June 2013 peritoneal fluid was detected and the appendix had Accepted: 25 July 2013 Published: 01 November 2013 perforated. During the operation, some fecaliths had

IJCRI – International Journal of Case Reports and Images, Vol. 4 No. 11, November 2013. ISSN – [0976-3198] IJCRI 2013;4(11):650–653. Katagiri et al. 651 www.ijcasereportsandimages.com

Figure 1: Computed tomography scan of the abdomen demonstrating a swelling appendix and fecaliths inside with a small amount of peritoneal fluid.

dropped into the peritoneal cavity. We retrieved the fecaliths, followed by removing the appendix. After surgery, a slight fever and paralytic ileus prolonged for several days. We suspected an intra- abdominal abscess, and CT scan of abdomen was done. The CT scan revealed small, high-density areas in the peritoneal cavity, which were compatible with retained fecaliths, and small abscesses around them (Figure 2A–B). As the patient refused further surgery, we administered antibiotics and decompression with a nasogastric tube. Fortunately, his symptom improved, and he was discharged after 22 days of surgery. Three months later, a check-up abdominal CT scan was done. The CT scan revealed no intra-abdominal abscess and the fecaliths had disappeared (Figure 3).

DISCUSSION

Acute appendicitis is one of the most common surgical emergencies in daily practice. It affects approximately 7% of the population over the lifetime [2]. There are Figure 2: (A, B) Computed tomography scans of axial and coronal several complications after appendectomy and the most views of the abdomen. Retained fecaliths and surrounding abscesses were detected (arrow). common is infection. It occurs typically in patients with a perforated appendicitis. In cases of perforated appendicitis, the risk of a dropped fecalith is high. It can also drop at the time of resection of the appendix, Compared with a gallstone, a retained fecalith has the during forceful extraction through the port, or when potential risk of causing an intra-abdominal abscess the appendix perforates [1]. Fecaliths are composed of [5]. Days to years can elapse between an appendectomy inspissated fecal material, mucus with trapped calcium and clinical manifestations of a retained fecalith [2, 6]. phosphate and inorganic salts [1]. To avoid spilled Patients with retained fecaliths present abdominal pain, fecaliths, gentle manipulation of the acutely inflamed or fever, elevated white blood cell count, or a combination gangrenous appendix and an endoscopic bag or pouch of these findings [2, 4]. In this patient, slight fever has to facilitate removal should be employed [5]. persisted but he did not complain of abdominal pain. A dropped gallstone during laparoscopic An intra-abdominal abscess due to a retained cholecystectomy is a relatively common complication. fecalith often relapses despite adequate drainage [4], However, a dropped and retained fecalith after so treatment should not only involve drainage but also appendectomy is rare and its frequency is unknown. removal of the fecalith. The management of a complicated

IJCRI – International Journal of Case Reports and Images, Vol. 4 No. 11, November 2013. ISSN – [0976-3198] IJCRI 2013;4(11):650–653. Katagiri et al. 652 www.ijcasereportsandimages.com

article, Critical revision of the article, Final approval of the version to be published Mai Ishitani – Conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Final approval of the version to be published Takashi Sakamoto – Analysis and interpretation of data, Critical revision of the article, Final approval of the version to be published Yasuo Yoshinaga – Conception and design, Analysis and interpretation of data, Critical revision of the article, Final approval of the version to be published Tadao Kubota – Conception and design, Analysis and interpretation of data, Drafting the article, Critical revision of the article, Final approval of the version to be Figure 3: Computed tomography scan of the abdomen, three published months after surgery. There was no evidence of a retained Akira Miyabe – Conception and design, Analysis and fecalith or abscess. interpretation of data, Critical revision of the article, Final approval of the version to be published fecalith most commonly described in literature is Guarantor open or laparoscopic surgery [1, 2, 4, 5]. Percutaneous The corresponding author is the guarantor of submission. extraction of the fecalith has also been reported [6]. Preoperative and intraoperative localization of fecalith Conflict of Interest using guidewire or intraoperative ultrasound as majority Authors declare no conflict of interest. of cases locating a fecalith can be difficult in laparoscopic surgery. Prevention of this complication should focus on Copyright avoidance of dropping fecaliths. © Hideki Katagiri et al. 2013; This article is distributed In this patient, the retained fecaliths were enclosed under the terms of Creative Commons attribution 3.0 by an intra-abdominal abscess and they caused License which permits unrestricted use, distribution and postoperative ileus. We considered surgical removal. reproduction in any means provided the original authors However, the patient refused surgery, and the location and original publisher are properly credited. (Please see of abscess was hard to approach percutaneously, so we www.ijcasereportsandimages.com/copyright-policy.php continued nonoperative management with antibiotics. for more information.) Fortunately, his symptoms improved and the retained fecaliths diminished. To our knowledge, this is the first reported case of retained fecaliths disappearing without REFERENCES surgical procedures. At present, the diagnosis of a fecalith is mainly based on 1. Maatouk M, Bunni J. Schuijtvlot M. Perihepatic CT scan. The CT scan can effectively detect calcification, abscess secondary to retained appendicolith: A rare so the feces, which are not calcified completely, might complication managed laparoscopically. J surg case be revealed as fecaliths. Such fecaliths can possibly be rep 2011;(1):6. treated as tiny abscesses. 2. Singh AK, Hahn PF, Gervais D, Vijayraghavan G, Mueller PR. Dropped appendicolith: CT findings and implications for management. AJR Am J Roentgenol 2008;190(3):707–11. CONCLUSION 3. Buckley O, Geoghegan T, Ridgeway P, Colhoun E, Snow A, Torreggiani WC. The usefulness of CT A retained fecalith after appendectomy is a rare guided drainage of abscesses caused by retained complication. However, surgeons have to be aware of this appendicoliths. Eur J Radiol 2006;60(1):80–3. rare complication. We have experienced a very rare case 4. Smith AG, Ripepi A, Stahlfeld KR. Retained fecalith: of retained fecaliths after laparoscopic appendectomy laparoscopic removal. Surg Laparosc Endosc which disappeared spontaneously with nonoperative Perccutan Tech 2002;12(6):441–2. management. In some patients with retained fecaliths, 5. Strathern DW, Jones BT. Retained fecalith there might be cases not requiring surgical procedures. after laparoscopic appendectomy. Surg Endosc 1999;13(3):287–9. 6. Rasuli P, Friendlich MS, Mahoney JE. Percutaneous ********* Retrieval of a Retained Appendicolith. Cardiovasc Intervent Radiol 2007;30(2):342–4. Author Contributions Hideki Katagiri – Conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the

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